Air Accident Investigation Unit Ireland
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Air Accident Investigation Unit Ireland IncIdent RepoRt Boeing 737-8AS, eI-enB Kerry Airport (eIKY), co. Kerry, Ireland 21 december 2010 Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010 AAIU Report No: 2012-004 State File No: IRL00910128 Published: 29/02/2012 In accordance with the provisions of SI 460 of 2009, the Chief Inspector of Air Accidents, on 22 December 2010, appointed Paddy Judge as the Investigator-in-Charge to carry out a Field Investigation into this Incident and prepare a Report. The sole purpose of this Investigation is the prevention of aviation Accidents and Incidents. It is not the purpose of the Investigation to apportion blame or liability. Aircraft Type and Registration: Boeing 737-8AS, EI-ENB No. and Type of Engines: 2 x CFM56-7B Aircraft Serial Number: 40289 Year of Manufacture: 2010 Date and Time (UTC): 21 December 2010 @ 09.13 hrs Location: Kerry Airport (EIKY), Co. Kerry, Ireland Type of Flight: Public Transport, Scheduled 2 Persons on Board: Crew - 7 Passengers - 170 Injuries: Crew - Nil Passengers - Nil Nature of Damage: None Commander’s Licence: JAA ATPL(A)1 Commander’s Details: Male, aged 47 years Commander’s Flying Experience: 13,000 hours, of which 6,100 were on type Notification Source: ATC Duty Manager Shannon Information Source: AAIU Field Investigation AAIU Report Form submitted by Commander 1 Joint Aviation Authorities Air Transport Pilot Licence (Aeroplane) Air Accident Investigation Unit Report 2012-004 SYNoPSIS Shortly after landing, smoke was observed in both the cockpit and cabin. The aircraft was stopped, the engines were shut down and an evacuation was carried out. No technical defect was found during the subsequent examination. It is probable that the smoke was caused by the engines ingesting granular urea, which had been used to de-ice the runway during a very cold weather period. NoTIFICATIoN The Air Accident Investigation Unit (AAIU) was first informed of the occurrence by the Air Traffic Control (ATC) Station Manager at Shannon. An AAIU Response Team of two Inspectors dispatched by rail in moderate snow to EIKY and arrived at 18.30 hrs. 1 FACTUAL INFoRMATIoN 1.1 History of the Flight The flight departed from Stansted Airport (EGSS) in the U.K. and flew directly to EIKY. The cockpit crew consisted of a Commander, who was an instructor pilot, a newly qualified First Officer (FO), who was making his first landing with passengers on board and a Safety Pilot (SP) occupying the jump seat. The FO was the Pilot Flying (PF) and the Commander was the Pilot Non-Flying (PNF). The weather conditions were good for the approach and the runway surface was reported dry. The descent, approach and landing were reported normal. After landing reverse thrust was selected. As the aircraft decelerated the SP reported smoke on the right hand side of the cockpit. The aircraft was turned off the runway and brought to a halt on the taxiway adjacent to the ramp. Shortly 3 afterwards the Cabin Services Supervisor (CSS) also reported smoke in the cabin. The engines were shut down and an evacuation was immediately commenced following which the passengers walked to the airport terminal building, a short distance away. 1.2 Commander The Commander reported that after an uneventful landing by the FO on Runway (RWY) 26 he took control of the aircraft at about 60 kts, as per normal procedure. At about 50 kts the SP reported smoke on the right hand side of the cockpit. This was followed by a call from the CSS that there was smoke in the cabin. At the time the aircraft was turning off the runway onto the taxiway. He reported that the smoke continued to thicken on the flight deck and he told the FO to don his oxygen mask as the smoke was dense on the right hand side of the cockpit. On hearing the call from the cabin he asked the SP to answer it and to open the cockpit door to view the cabin. He stated that he was unable to see the back of the cabin clearly due to “grey/blue slightly acrid smoke”. Based on this assessment he decided to immediately evacuate the aircraft, this being the safest option. He then shut down the engines and carried out the evacuation procedures. Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010 1.3 Safety Pilot (SP) The SP stated that ATC had reported that the runway was dry for landing. The landing, which was conducted with flaps at 40 and auto-brake setting at 3, was smooth and normal reverse thrust was used. During the landing roll he saw blue/violet smoke on the right hand side of the flight deck, which he reported. The smoke or mist was acrid and affected the back of his throat. He answered a call from the CSS who told him that there was smoke in the cabin. When the aircraft had stopped he opened the door and looked back down the cabin. He stated that he could see about half-way down the cabin. He made a “PAN2” transmission to ATC and said that the Fire Services reacted very promptly to this call. He stated that the Auxiliary Power Unit (APU) was not started after shutdown. 1.4 Cabin Services Supervisor (CSS) The CSS reported that when he observed vapour like steam all over the cabin after landing he called the cockpit. He said that the vapour appeared very dense in the flight deck when the cockpit door was opened and that it seemed to be getting denser in the cabin at the time. He said that he had never seen this amount of vapour in the cabin before but that he had heard that an incident of a similar nature had happened to a company aircraft some weeks previously, which he believed might have been due to de-icing fluid. He had tried to communicate this to the SP who answered his call from the cockpit. 4 Following the Commander’s order to evacuate, which was given over the public address (PA) system, he and the crew immediately commenced an evacuation using all exits. He stated that during the evacuation all four door slides were used as well as three of the four over- wing exits and that the evacuation was completed in about 30 seconds. The CSS reported that a passenger had been unable to open one over-wing exit, which was therefore unused. However, it was subsequently found to be serviceable when checked. The over-wing exits were not manned by the cabin crew but a passenger close to each had been earlier briefed on how to open it. He reported that it was very difficult to deal with those passengers who brought carry-on baggage with them during the evacuation, even though they had been told not to bring anything. He said that it was not possible to remove hand baggage from individuals during the evacuation without disrupting the evacuation flow and reducing the rate of egress of passengers. He stated that crowd control outside the aircraft was difficult, even though he used a loud hailer. 1.5 Injuries to Persons No injuries were reported to the Investigation. 1.6 Damage to Aircraft The aircraft was not damaged. 2 PAN: When a “PAN-PAN” radio transmission is repeated three times it indicates that an urgent message about the safety of the aircraft is being transmitted. Air Accident Investigation Unit Report 2012-004 1.7 Licences The Commander’s licence was a Joint Aviation Authorities (JAA) Airline Transport Pilot Licence (ATPL), issued by the Civil Aviation Authority (CAA) UK. His licence, type rating and Class One medical certificate were valid. He had a total of 13,000 flying hours of which 6,100 hours were on the B737-800 type. The SP held a JAA ATPL licence, issued by the Irish Aviation Authority (IAA). His licence, type rating and Class One medical certificate were valid. He had a total of 2,600 flying hours of which 2,300 hours were on the B737-800 type. The FO held a JAA Commercial Pilot Licence (CPL), issued by the IAA. His licence, type rating and Class One medical certificate were valid. He had a total of 322 flying hours of which 2.5 hours were on the B737-800 type. The training record for each cabin crew member was found to be current. 1.8 Hand Baggage Airport security cameras recorded that the first Fire Service appliance arrived at the aircraft 22 seconds after the aircraft came to a halt. One minute and five seconds later the port doors opened, the slides inflated and passengers immediately began to leave the aircraft. The security cameras (Photo No. 1) recorded that a significant number of the passengers carried hand baggage as they walked towards the airport terminal building. 5 Photo No. 1: Passengers after emergency evacuation. Boeing 737-8AS EI-ENB Kerry Airport, Ireland 21 December 2010 The International Civil Aviation Organisation (ICAO) Training Manual, Document 7192, Part D-3 contains procedures regarding carry-on/hand baggage. However, the National Transportation Safety Board (NTSB) of the United States, in a Safety Study3 of 46 emergency evacuations published in 2000, identified that nearly 50 per cent of passengers who brought carry-on luggage on board attempted to remove a bag during emergency evacuations. Reports issued by other investigative authorities on other evacuations have found that some passengers have resisted the removal of carry-on baggage by cabin crew, thereby disrupting orderly evacuation. 1.9 Weather The weather report for EIKY at the time of the incident was that the wind was calm; the visibility was in excess of 10 km.